Concrements of the Lacrimal Apparatus

Abstract

Concrements of the lacrimal apparatus, known as dacryoliths, can occur at different localizations and can cause a variety of symptoms. A common clinical sign is chronic inflammation, possibly exhibiting acute exacerbation. Based on a literature review and descriptive clinical cases with histopathological correlations, this contribution summarises the most important information concerning epidemiology, aetiopathogenesis, composition, histology, and therapy of lacrimal concrements. Furthermore, factors known to affect lacrimal lithogenesis are addressed. Concrements of the lacrimal gland cause a swelling at the lateral canthus. With only mild pain, this manifests as circumscribed conjunctival hyperaemia. Histologically, the gland tissue is characterised by acute-erosive to chronic inflammation. The concrements consist of amorphic material. Inflammatory infiltration is dominated by neutrophil granulocytes. Canalicular concrements are highly correlated with chronic canaliculitis. Besides epiphora, patients present with purulent discharge at the affected canaliculus. Actinomyces are frequently found inside these deposits and form drusen-like formations. The surrounding tissue reacts with plasma-cellular and granulocytic inflammation. Dacryoliths (concrements of the lacrimal sac) are associated with dacryocystitis, whereby acute and chronic types are common. Stones can be found in up to 18% of patients undergoing dacryocystorhinostomy or dacryoendoscopy. Preoperative diagnostic testing is challenging, as many lacrimal sac stones cannot be reliably visualised by diagnostic procedures. Recurring episodes of epiphora, mucopurulent discharge, and dacryocystitis are common indicators of dacryoliths. Lacrimal syringing is often possible and shows that total blockage is not present. Histology of the lacrimal mucosa reveals lymphocytic infiltration and submucosal fibrosis. The immediate vicinity of the dacryoliths shows acute inflammation. Therapy consists of stone extraction and improving lacrimal drainage, as the latter is recognised as the main risk factor for dacryolith formation.

Key words

lacrimal gland concrement - dacryolith - canalicular concrement - dacryoadenitis - dacryocystitis - canaliculitis

Publication History

Received: 11 October 2022

Accepted: 03 November 2022

Article published online:
27 January 2023

• References/Literatur

• 1 Traquair HM. Chronic dacryocystitis: its causation and treatment. Arch Ophthalmol 1941; 26: 165-180
• 2 Halborg J, Prause JU, Toft PB. et al. Stones in the lacrimal gland: a rare condition. Acta Ophthalmol 2009; 87: 672-675
• 3 Baratz KH, Bartley GB, Campbell RJ. et al. An eyelash nidus for dacryoliths of the lacrimal excretory and secretory systems. Am J Ophthalmol 1991; 111: 624-627
• 4 Mawn LA, Sanon A, Conlon MR. et al. Pseudomonas dacryoadenitis secondary to a lacrimal gland ductule stone. Ophthalmic Plast Reconstr Surg 1997; 13: 135-138
• 5 Baker RH, Bartley GB. Lacrimal gland ductule stones. Ophthalmology 1990; 97: 531-534
• 6 Norn MS. Tear fluid pH in normals, contact lens wearers, and pathological cases. Acta Ophthalmol 1988; 66: 485-489
• 7 Lew H, Lee SY, Yun YS. Measurement of pH, electrolytes and electrophoretic studies of tear proteins in tears of patients with dacryoliths: a novel concept for dacryoliths. Ophthalmologica 2004; 218: 130-135
• 8 Holtmann C, Brachert M, Spaniol K. et al. Dakryolith der zuführenden Tränenwege. Ophthalmologe 2016; 113: 244-247
• 9 Gaca PJ, Rejdak R, Doulis A. et al. Ungewöhnliche druckindolente Raumforderung im temporalen Lidwinkel. Ophthalmologie 2022;
• 10 Naito H, Oshida K, Kurokawa K. et al. Atypical intermittent exophthalmos due to hyperplasia of lacrimal gland associated with dacryolithiasis. Surg Neurol 1973; 1: 84-86
• 11 Zafar A, Jordan DR, Brownstein S. et al. Asymptomatic lacrimal ductule dacryolithiasis with embedded cilia. Ophthalmic Plast Reconstr Surg 2004; 20: 83-85
• 12 Repp DJ, Burkat CN, Lucarelli MJ. Lacrimal excretory system concretions: canalicular and lacrimal sac. Ophthalmology 2009; 116: 2230-2235
• 13 Struck HG, Höhne C, Tost M. Zur Diagnostik und Therapie der chronischen Canaliculitis. Ophthalmologe 1992; 89: 233-236
• 14 Fulmer NL, Neal JG, Bussard GM. et al. Lacrimal canaliculitis. Am J Emerg Med 1999; 17: 385-386
• 15 Vujancević S, Meyer-Rüsenberg HW. Therapie der Aktinomykose der ableitenden Tränenwege. Klin Monbl Augenheilkd 2010; 227: 568-574
• 16 Kim UR, Wadwekar B, Prajna L. Primary canaliculitis: The incidence, clinical features, outcome and long-term epiphora after snip-punctoplasty and curettage. Saudi J Ophthalmol 2015; 29: 274-277
• 17 Vécsei VP, Huber-Spitzy V, Arocker-Mettinger E. et al. Canaliculitis: difficulties in diagnosis, differential diagnosis and comparison between conservative and surgical treatment. Ophthalmologica 1994; 208: 314-317
• 18 Baldursdottir E, Sigurdsson H, Jonasson L. et al. Actinomycotic canaliculitis: resolution following surgery and short topical antibiotic treatment. Acta Ophthalmol 2010; 88: 367-370
• 19 Funke G. Actinomyces spp. und verwandte fakultativ anaerobe grampositive Stäbchen. In: Neumeister B, Geiss HK, Braun RW, Kimmig P. Hrsg. Mikrobiologische Diagnostik. Stuttgart, New York: Thieme; 2009: 533-539
• 20 Heichel J, Sandner A, Siebolts U. et al. Konkremente und iatrogene Fremdkörper der ableitenden Tränenwege: Therapeutische Empfehlungen. HNO 2016; 64: 403-416
• 21 Briscoe D, Edelstein E, Zacharopoulos I. et al. Actinomyces canaliculitis: diagnosis of a masquerading disease. Graefes Arch Clin Exp Ophthalmol 2004; 242: 682-686
• 22 Freedman JR, Markert MS, Cohen AJ. Primary and secondary lacrimal canaliculitis: a review of literature. Surv Ophthalmol 2011; 56: 336-347
• 23 Stucki VC, Demolli P, Kniestedt C. et al. Langzeitverlaufsstudie von Kanalikulotomien nach Kanalikulitis. Klin Monbl Augenheilkd 2018; 235: 392-397
• 24 Demant E, Hurwitz JJ. Canaliculitis: review of 12 cases. Can J Ophthalmol 1980; 15: 73-75
• 25 Anand S, Hollingworth K, Kumar V. et al. Canaliculitis: the incidence of long-term epiphora following canaliculotomy. Orbit 2004; 23: 19-26
• 26 Goel R, Malik KP, Gaind R. et al. Bilateral actinomycotic blepharokeratoconjunctivitis. Orbit 2007; 26: 53-55
• 27 McKellar MJ, Aburn NS. Cast-forming Actinomyces israelii canaliculitis. Aust N Z J Ophthalmol 1997; 25: 301-303
• 28 Singh CN, Thakker M, Sires BS. Pyogenic granuloma associated with chronic Actinomyces canaliculitis. Ophthalmic Plast Reconstr Surg 2006; 22: 224-225
• 29 Lee MJ, Choung HK, Kim NJ. et al. One-snip punctoplasty and canalicular curettage through the punctum: a minimally invasive surgical procedure for primary canaliculitis. Ophthalmology 2009; 116: 2027-2030.e2
• 30 Berlin AJ, Rath R, Rich L. Lacrimal system dacryoliths. Ophthalmic Surg 1980; 11: 435-436
• 31 Hawes MJ. The dacryolithiasis syndrome. Ophthalmic Plast Reconstr Surg 1988; 4: 87-90
• 32 Yazici B, Hammad AM, Meyer DR. Lacrimal sac dacryoliths: predictive factors and clinical characteristics. Ophthalmology 2001; 108: 1308-1312
• 33 Mishra K, Hu KY, Kamal S. et al. Dacryolithiasis: A Review. Ophthalmic Plast Reconstr Surg 2017; 33: 83-89
• 34 Kubo M, Sakuraba T, Wada R. Clinicopathological features of dacryolithiasis in Japanese patients: frequent association with infection in aged patients. ISRN Ophthalmol 2013; 2013: 406153
• 35 Komínek P, Doškářová S, Svagera Z. et al. Lacrimal sac dacryoliths (86 samples): chemical and mineralogic analyses. Graefes Arch Clin Exp Ophthalmol 2014; 252: 523-529
• 36 Thale A, Paulsen F, Rochels R. et al. Functional anatomy of the human efferent tear ducts: a new theory of tear outflow mechanism. Graefes Arch Clin Exp Ophthalmol 1998; 236: 674-678
• 37 Andreou P, Rose GE. Clinical presentation of patients with dacryolithiasis. Ophthalmology 2002; 109: 1573-1574
• 38 Heichel J, Struck HG, Bredehorn-Mayr T. Chronische Dakryozystitis im Kindesalter: Transkanalikuläre endoskopiegestützte Entfernung iatrogener intrasakkaler Fremdkörper. Ophthalmologe 2014; 111: 862-865
• 39 Jones LT. Tear-sac foreign bodies. Am J Ophthalmol 1965; 60: 111-113
• 40 Wilkins RB, Pressly JP. Diagnosis and incidence of lacrimal calculi. Ophthalmic Surg 1980; 11: 787-789
• 41 Ali MJ, Schicht M, Heichel J. et al. Electron microscopic features of the lacrimal sac mucopeptide concretions. Graefes Arch Clin Exp Ophthalmol 2018; 256: 1313-1318
• 42 Paulsen FP, Schaudig U, Fabian A. et al. TFF peptides and mucins are major components of dacryoliths. Graefes Arch Clin Exp Ophthalmol 2006; 244: 1160-1170
• 43 Ali MJ, Scholz M, Singh S. et al. Etiopathogenesis of lacrimal sac mucopeptide concretions: insights from cinematic rendering techniques. Graefes Arch Clin Exp Ophthalmol 2020; 258: 2299-2303
• 44 Perry LJ, Jakobiec FA, Zakka FR. Bacterial and mucopeptide concretions of the lacrimal drainage system: an analysis of 30 cases. Ophthalmic Plast Reconstr Surg 2012; 28: 126-133
• 45 Iliadelis E, Karabatakis V, Sofoniou M. Dacryoliths in chronic dacryocystitis and their composition (spectrophotometric analysis). Eur J Ophthalmol 1999; 9: 266-268
• 46 Ozer S, Ozer PA, Ortarik Z. et al. Analysis of inorganic elements in a dacryolith using polarised X-ray fluorescence spectrometry: a case report. Eye (Lond) 2012; 26: 887
• 47 Orhan M, Onerci M, Dayanir V. et al. Lacrimal sac dacryolith: a study with atomic absorption spectrophotometry and scanning electron microscopy. Eur J Ophthalmol 1996; 6: 478-480
• 48 Iliadelis ED, Karabatakis VE, Sofoniou MK. Dacryoliths in a series of dacryocystorhinostomies: histologic and chemical analysis. Eur J Ophthalmol 2006; 16: 657-662
• 49 Heindl LM, Junemann A, Holbach LM. A clinicopathologic study of nasal mucosa in 350 patients with external dacryocystorhinostomy. Orbit 2009; 28: 7-11
• 50 Dhillon N, Kreis AJ, Madge SN. Dacryolith-induced acute dacryocystitis: a reversible cause of nasolacrimal duct obstruction. Orbit 2014; 33: 199-201
• 51 Guthoff R, Lieb WE. Dakryozystotomie und mikrochirurgische Tränensackrekonstruktion bei Dakryolithen. Ophthalmologe 2002; 99: 113-115
• 52 Völkerling A, Struck HG, Kunert KS. et al. Dakryoendoskopische Tränenwegschirurgie – Einflussfaktoren auf das postoperative Ergebnis. Klin Monbl Augenheilkd 2018; 235: 24-30
• 53 Komínek P, Červenka S, Zeleník K. et al. Lacrimal sac dacryolith (76 cases): a predictive factor for successful endonasal dacryocystorhinostomy?. Eur Arch Otorhinolaryngol 2014; 271: 1595-1599
• 54 Rokohl AC, Guo Y, Mor JM. et al. Intubationssysteme in der Tränenwegchirurgie – eine aktuelle Übersicht. Klin Monbl Augenheilkd 2020; 237: 20-28
• 55 Lee JM, Baek JS. Etiology of Epiphora. Korean J Ophthalmol 2021; 35: 349-354
• 56 Tost F, Bruder R, Clemens S. 20-MHz-Ultraschall der präsakkalen Tränenwege. Ophthalmologe 2002; 99: 25-28